Early Blood Transfusion Research Articles

Shock index, pediatric age-adjusted (SIPA) is more accurate than age-adjusted hypotension for trauma team activation

We demonstrated previously that shock index, pediatric age-adjusted identifies severely injured children accurately after blunt trauma. We hypothesized that an increased shock index, pediatric age-adjusted would identify more accurately injured children requiring the highest trauma team activation than age-adjusted hypotension. We reviewed all children age 4-16 admitted after blunt trauma with an injury severity score ≥15 from January 2007-June 2013. Criteria used as indicators of need for activation of the trauma team included blood transfusion, emergency operation, or endotracheal intubation within 24hours of admission. Shock index, pediatric age-adjusted represents maximum normal shock index based on age. Cutoffs included shock index >1.22 (ages 4-6), >1.0 (7-12), and >0.9 (13-16). Age-adjusted cutoffsfor hypotension were as follows: systolic blood pressure <90 (ages 4-6), systolic blood pressure <100 (7-16). A total of 559 children were included; 21% underwent operation, 37% endotracheal intubation, and 14% transfusion. Hypotension alone predicted poorly the need for operation (13%), endotracheal intubation (17%), or transfusion (22%). Operation (30%), endotracheal intubation (40%), and blood transfusion (53%) were more likely in children with an increased shock index, pediatric age-adjusted; 25 children required all three interventions, 3 (12%) were hypotensive at presentation, 15 (60%) had an increased shock index, pediatric age-adjusted (P<.001). An increased shock index, pediatric age-adjusted is superior to age-adjusted hypotension to identify injured children likely to require emergency operation, endotracheal intubation, or early blood transfusion.

Advances in military resuscitation

Trauma is a leading cause of death and disability worldwide, in civilian environments and on the battlefield. Trauma-induced haemorrhage is the principal cause of potentially preventable death, which is generally attributable to a combination of vascular injury and coagulopathy. Survival rates following severe traumatic injury have increased due to advanced trauma management initiatives and treatment protocols, influenced by lessons learned from recent conflicts in Iraq and Afghanistan.The use of tourniquets and intraosseous needles, early blood and blood product transfusion, administration of tranexamic acid in pre-hospital settings, and consultant-led damage control resuscitation incorporating damage control surgery have all played their part. All are quantified by trauma governance processes, including a robust trauma registry. Some of the lessons learned in combat are equally applicable to civilian environments, and this article describes several of the most important of these. It also gives an overview of advancements in UK military trauma management of severely injured combat casualties, honed over a decade of conflict.

Advances in military resuscitation.

Trauma is a leading cause of death and disability worldwide, in civilian environments and on the battlefield. Trauma-induced haemorrhage is the principal cause of potentially preventable death, which is generally attributable to a combination of vascular injury and coagulopathy. Survival rates following severe traumatic injury have increased due to advanced trauma management initiatives and treatment protocols, influenced by lessons learned from recent conflicts in Iraq and Afghanistan. The use of tourniquets and intraosseous needles, early blood and blood product transfusion, administration of tranexamic acid in pre-hospital settings, and consultant-led damage control resuscitation incorporating damage control surgery have all played their part. All are quantified by trauma governance processes, including a robust trauma registry. Some of the lessons learned in combat are equally applicable to civilian environments, and this article describes several of the most important of these. It also gives an overview of advancements in UK military trauma management of severely injured combat casualties, honed over a decade of conflict.

353 Descriptive Analysis of Early Blood Transfusions at an Urban Trauma Center

353 Descriptive Analysis of Early Blood Transfusions at an Urban Trauma Center

Elevated admission international normalized ratio strongly predicts mortality in victims of abusive head trauma.

Victims of abusive head trauma have poor outcomes compared with other injured children. There is often a delay in diagnosis because these young patients are unable to communicate with health care providers. These critically injured patients would benefit from early identification and therapy. We performed a retrospective review of our single hospital trauma registry from 2005 to 2014. All Level 1 pediatric (age 0-17 years) trauma patients who sustained abusive head trauma were included. Exclusion criteria included no admission coagulation studies, prehospital product transfusion, preexisting coagulation disorder, or death upon arrival. Primary outcome was mortality; secondary outcomes were early blood transfusion and neurosurgical intervention. Univariate analysis included Fisher's exact and Wilcoxon rank-sum testing; we then performed logistic regression modeling and calculated adjusted odds ratios (AORs) to control for known predictors of poor outcome including hypotension, hypothermia, acidosis, Injury Severity Score (ISS), and head Abbreviated Injury Scale (AIS) score. In 101 total subjects, 35% (n = 35) had international normalized ratio (INR) of 1.3 or greater at admission. On univariate analysis, patients with coagulation dysregulation were more likely to have hypothermia, hypotension, acidosis, high ISS, and low Glasgow Coma Scale (GCS) score (all p < 0.05). There was no difference in age, anemia, and incidence of polytrauma. Overall mortality was 24.8% (n = 25), which varied significantly based at admission INR (60% INR ≥ 1.3 vs. 6% INR > 1.3, p < 0.001). Patients with elevated INR were also more likely to have early packed red blood cell transfusion (p = 0.003) and neurosurgical intervention (p = 0.011). In logistic regression analysis, admission INR was the strongest independent predictor of mortality, with increased odds of 3.65 (p = 0.045). AOR after controlling specifically for hypotension, hypothermia, and acidosis was 6.25 (p = 0.006), and after controlling for head AIS score and admission GCS score, the AOR was 5.27 (p = 0.007). Admission INR of 1.3 or greater strongly predicts mortality in abusive head trauma. These patients should be targeted for early aggressive interventions and monitoring with the goal of improving patient outcomes. Further study is warranted to investigate potential therapeutic targets in trauma-induced coagulation dysregulation. Prognostic and epidemiologic study, level III.

Nonoperative Management Is as Effective as Immediate Splenectomy for Adult Patients with High-Grade Blunt Splenic Injury

The comparative effectiveness of nonoperative management (NOM) vs immediate splenectomy (IS) for hemodynamically stable adult patients with grade IV or V blunt splenic injury (BSI) has not been clearly established in the literature. We performed a retrospective analysis of adult patients, from the 2013 to 2014 American College of Surgeons Trauma Quality Improvement Program (TQIP) Participant Use Data Files, who sustained grade IV or V BSI. Outcomes after IS vs attempted NOM were compared using propensity score analysis in order to adjust for patient- and injury-related variables. Nonoperative management was attempted in 1,489 (52.2%) of 2,746 patients who sustained grade IV or V BSI. Propensity matching techniques resulted in a cohort of 758 IS and NOM patients who were well matched for all known patient- and injury-related variables. In-hospital mortality was not different between the IS and NOM patients (11.5% vs 10.0%, p= 0.33), although IS patients had a higher incidence of infectious complications (21.4% vs 16.9%, p= 0.02). The rate of NOM failure in our sample was 20.1%. Independent predictors of failed NOM included the presence of a bleeding disorder, early blood transfusion requirement, and grade V injury. Splenic artery embolization was associated with a decreased risk of NOM failure. Patients who had failed NOM had a lower in-hospital mortality rate than IS patients (6.4% vs 16.4%, p= 0.004), but required longer hospitalization. Nonoperative management is as effective as IS for hemodynamically stable adult patients with grade IV or V BSI. The delay in operative intervention that results from failed attempts at NOM does not adversely affect the outcomes of patients who ultimately require splenectomy.

Impact of Early Blood Transfusion After Kidney Transplantation on the Incidence of Donor-Specific Anti-HLA Antibodies.

Little is known about the impact of posttransplant blood transfusion on the sensitization of anti-HLA antibodies and the formation of donor-specific antibodies (DSAs). The aims of our study were to determine the 1-year incidence of DSAs (assessed using a solid-phase assay) and antibody-mediated rejection (AMR) in kidney transplant patients who had or had not received a blood transfusion during the first year after transplantation. Included were 390 non-HLA-sensitized patients who had received an ABO-compatible kidney transplant and had not previously or simultaneously received a nonkidney transplant. Overall, 64% of patients received a red blood cell transfusion within the first year after transplantation, most within the first month. The overall 1-year incidence of DSAs was significantly higher in patients that had undergone transfusion (7.2% vs. 0.7% in patients with no transfusion, p < 0.0001). AMR occurred more often in the transfusion group (n = 15, 6%) compared with the nontransfusion group (n = 2, 1.4%; p = 0.04). Blood transfusion was an independent predictive factor for de novo DSA formation but not for AMR. Patients who had a transfusion and developed DSAs were more often treated with cyclosporin A (n = 10, 55.5%) rather than tacrolimus (n = 45, 19.4%; p = 0.0001). In conclusion, early posttransplant blood transfusion may increase immunological risk, especially in underimmunosuppressed patients.

Notching in the Umbilical Artery Doppler Waveform in the Absence of Cord and Placental Structural Abnormalities: A Case of Massive Fetomaternal Hemorrhage

Massive fetomaternal hemorrhage can cause severe anemia and fetal death. Early diagnosis and blood transfusion can prevent life-threatening events. We describe a case of massive fetomaternal hemorrhage in a previously well primigravida who visited our hospital with a chief complaint of decreased fetal movements and presented with a sinusoidal fetal heart rate pattern in the cardiotocographic tracings. The umbilical artery Doppler waveform showed notching, and the peak systolic velocity of the fetal middle cerebral artery (MCA) was normal. Emergency cesarean section was performed; however, the neonate died despite providing life-support. Thus, we recommend consideration of impending fetal death in patients with non-reassuring fetal heart rate and notching in the umbilical artery Doppler waveform even in the absence of increased peak systolic velocity of the fetal MCA. J Clin Gynecol Obstet. 2016;5(1):50-52 doi: http://dx.doi.org/10.14740/jcgo386w

Massive transfusion protocols: current best practice

Massive transfusion protocols (MTPs) are established to provide rapid blood replacement in a setting of severe hemorrhage. Early optimal blood transfusion is essential to sustain organ perfusion and oxygenation. There are many variables to consider when establishing an MTP, and studies have prospectively evaluated different scenarios and patient populations to establish the best practices to attain improved patient outcomes. The establishment and utilization of an optimal MTP is challenging given the ever-changing patient status during resuscitation efforts. Much of the MTP literature comes from the trauma population, due to the fact that massive hemorrhage is the leading cause of preventable trauma-related death. As we come to further understand the positive and negative clinical impacts of transfusion-related factors, massive transfusion practice can be further refined. This article will first discuss specific MTPs targeting different patient populations and current relevant international guidelines. Then, we will examine a wide selection of therapeutic products to support MTPs, including newly available products and the most suitable of the traditional products. Lastly, we will discuss the best design for an MTP, including ratio-based MTPs and MTPs based on the use of point-of- care coagulation diagnostic tools.

“The Tramp”, a blood donation propagandist?

The French pioneer for blood transfusion, who eventually organized the very early blood transfusion centers worldwide, went to imagine a scenario written in purpose for Charlie Chaplin, the unique character of “The Tramp” (“Charlot” in French). The movie Star was offered to feature a blood donation propagandist, and no longer the perpetual, well-known, “loser”. This anecdote, besides being amusing, tells a lot on how Arnault Tzank encompassed all the difficulties in collecting blood enough to meet the demand, at all times; his proposal turns out to be extremely modern and questions nowadays marketing for blood donation.

A Derivation and Validation Study of an Early Blood Transfusion Needs Score for Severe Trauma Patients.

BackgroundThere is no existing adequate blood transfusion needs determination tool that Emergency Medical Services (EMS) personnel can use for prehospital blood transfusion initiation. In this study, a simple and pragmatic prehospital blood transfusion needs scoring system was derived and validated.MethodsLocal trauma registry data were reviewed retrospectively from 2004 through 2013. Patients were randomly assigned to derivation and validation cohorts. Multivariate logistic regression was used to identify the independent approachable risks associated with early blood transfusion needs in the derivation cohort in which a scoring system was derived. Sensitivity, specificity, and area under the receiver operational characteristic (AUC) were calculated and compared using both the derivation and validation data.ResultsA total of 24,303 patients were included with 12,151 patients in the derivation and 12,152 patients in the validation cohorts. Age, penetrating injury, heart rate, systolic blood pressure, and Glasgow coma scale (GCS) were risks predictive of early blood transfusion needs. An early blood transfusion needs score was derived. A score > 5 indicated risk of early blood transfusion need with a sensitivity of 83% and a specificity of 80%. A sensitivity of 82% and a specificity of 80% were also found in the validation study and their AUC showed no statistically significant difference (AUC of the derivation = 0.87 versus AUC of the validation = 0.86, P > 0.05).ConclusionsAn early blood transfusion scoring system was derived and internally validated to predict severe trauma patients requiring blood transfusion during prehospital or initial emergency department resuscitation.

The History of the Foundation of the Iranian National Blood Transfusion Service in 1974 and the Biography of its Founder; Professor Fereydoun Ala.

The history of early attempts of blood transfusion in Iran traces back to the 1940s; however, around three decades later in 1974, the Iranian National Blood Transfusion Service (Sazeman-e Melli-e Enteqal-e Khun-e Iran) was founded by the outstanding hematologist, Professor Fereydoun Ala. The main goals of this centralized organization were to collect blood from healthy voluntary donors, to screen the donated blood and to provide various safe blood products based on scientific and ethical standards. In due course, a new era of blood transfusion service in Iran had begun to such a degree that after more than four decades of its activity, it is now considered the best-developed blood service in the eastern Mediterranean region. Here, a brief historical account of the early blood transfusion efforts and the establishment of the modern Iranian National Blood Transfusion Service in Iran is discussed in addition to the life and career of its founder and first director, Professor Fereydoun Ala.

Early autologous fresh whole blood transfusion leads to less allogeneic transfusions and is safe.

The practice of transfusing ones' own shed whole blood has obvious benefits such as reducing the need for allogeneic transfusions and decreasing the need for other fluids that are typically used for resuscitation in trauma. It is not widely adopted in the trauma setting because of the concern of worsening coagulopathy and the inflammatory process. The aim of this study was to assess outcomes in trauma patients receiving whole blood autotransfusion (AT) from hemothorax. This is a multi-institutional retrospective study of all trauma patients who received autologous whole blood transfusion from hemothorax from two Level I trauma centers. Patients who received AT were matched to patients who did not receive AT (No-AT) using propensity score matching in a 1:1 ratio for admission age, sex, mechanism, type of injury, Injury Severity Score (ISS), Glasgow Coma Scale (GCS) score, systolic blood pressure, heart rate, hemoglobin, international normalized ratio (INR), prothrombin time, partial prothrombin time, and lactate. AT was defined as transfusion of autologous blood from patient's hemothorax, which was collected from the chest tubes and anticoagulated with citrate phosphorous dextrose. Outcome measures were in-hospital complications, 24-hour INR, and mortality. In-hospital complications were defined as adult respiratory distress syndrome, sepsis, disseminated intravascular coagulation, renal insufficiency, and transfusion-related acute lung injury. A total of 272 patients (AT, 136; No-AT, 136) were included. There was no difference in admission age (p = 0.6), ISS (p = 0.56), head Abbreviated Injury Scale (AIS) score (p = 0.42), systolic blood pressure (p = 0.88), and INR (p = 0.62) between the two groups. There was no significant difference in in-hospital complications (p = 0.61), mortality (p = 0.51), and 24-hour postadmission INR (0.31) between the AT and No-AT groups. Patients who received AT had significantly lower packed red blood cell (p = 0.01) and platelet requirements (p = 0.01). Cost of transfusions (p = 0.01) was significantly lower in the AT group compared with the No-AT group. The autologous transfusion of the patient's shed blood collected through chest tubes for hemothorax was found to be safe without complications in this study. It also reduced the need for allogeneic transfusions and decreased hospital costs. This study demonstrates safety data that would help in designing larger prospective multicenter studies to determine whether this practice is truly safe and effective. Epidemiologic/prognostic study, level III.

Analysis of complications after blood components' transfusions.

Complications after blood components still constitute an important clinical problem and serve as limitation of liberal-transfusion strategy. The aim of the study was to present the 5-year incidence of early blood transfusions complications and to assess their relation to the type of the transfused blood components. 58,505 transfusions of blood components performed in the years 2006-2010 were retrospectively analyzed. Data concerning the amount of the transfused blood components and the numbers of adverse transfusion reactions reported to the Regional Blood Donation and Treatment Center (RBDTC) was collected. 95 adverse transfusion reactions were reportedto RBDTC 0.16% of alldonations (95/58 505) - 58 after PRBC transfusions, 28 after platelet concentrate transfusions and 9 after FFP transfusion. Febrile nonhemolytic and allergic reactions constitute respectively 36.8% and 30.5% of all complications. Nonhemolyticand allergic reactions are the most common complications of blood components transfusion and they are more common after platelet concentrate transfusions in comparison to PRBC and FFP donations.

Effect of thromboelastography (TEG®) and rotational thromboelastometry (ROTEM®) on diagnosis of coagulopathy, transfusion guidance and mortality in trauma: descriptive systematic review.

IntroductionThe understanding of coagulopathies in trauma has increased interest in thromboelastography (TEG®) and thromboelastometry (ROTEM®), which promptly evaluate the entire clotting process and may guide blood product therapy. Our objective was to review the evidence for their role in diagnosing early coagulopathies, guiding blood transfusion, and reducing mortality in injured patients.MethodsWe considered observational studies and randomized controlled trials (MEDLINE, EMBASE, and Cochrane databases) to February 2014 that examined TEG®/ROTEM® in adult trauma patients. We extracted data on demographics, diagnosis of early coagulopathies, blood transfusion, and mortality. We assessed methodologic quality by using the Newcastle-Ottawa scale (NOS) for observational studies and QUADAS-2 tool for diagnostic accuracy studies.ResultsFifty-five studies (12,489 patients) met inclusion criteria, including 38 prospective cohort studies, 15 retrospective cohort studies, two before-after studies, and no randomized trials. Methodologic quality was moderate (mean NOS score, 6.07; standard deviation, 0.49). With QUADAS-2, only three of 47 studies (6.4%) had a low risk of bias in all domains (patient selection, index test, reference standard and flow and timing); 37 of 47 studies (78.8%) had low concerns regarding applicability. Studies investigated TEG®/ROTEM® for diagnosis of early coagulopathies (n = 40) or for associations with blood-product transfusion (n = 25) or mortality (n = 24). Most (n = 52) were single-center studies. Techniques examined included rapid TEG® (n =12), ROTEM® (n = 18), TEG® (n = 23), or both TEG® and rapid TEG® (n = 2). Many TEG®/ROTEM® measurements were associated with early coagulopathies, including some (hypercoagulability, hyperfibrinolysis, platelet dysfunction) not assessed by routine screening coagulation tests. Standard measures of diagnostic accuracy were inconsistently reported. Many abnormalities predicted the need for massive transfusion and death, but predictive performance was not consistently superior to routine tests. One observational study suggested that a ROTEM®-based transfusion algorithm reduced blood-product transfusion, but TEG®/ROTEM®-based resuscitation was not associated with lower mortality in most studies.ConclusionsLimited evidence from observational data suggest that TEG®/ROTEM® tests diagnose early trauma coagulopathy and may predict blood-product transfusion and mortality in trauma. Effects on blood-product transfusion, mortality, and other patient-important outcomes remain unproven in randomized trials.Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-014-0518-9) contains supplementary material, which is available to authorized users.

Timing and volume of fluid administration for patients with bleeding

Treatment of haemorrhagic shock involves maintaining blood pressure and tissue perfusion until bleeding is controlled. Different resuscitation strategies have been used to maintain the blood pressure in trauma patients until bleeding is controlled. However, while maintaining blood pressure may prevent shock, it may worsen bleeding. To examine the effect on mortality and coagulation times of two intravenous fluid administration strategies in the management of haemorrhagic hypovolaemia, early compared to delayed administration and larger compared to smaller volume of fluid administered. We searched the Cochrane Injuries Group Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, Ovid MEDLINE(R), Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily and Ovid OLDMEDLINE(R), Embase Classic + Embase (OvidSP), ISI Web of Science (SCI-Expanded and CPCI-S) and clinical trials registries. We checked reference lists of identified articles and contacted authors and experts in the field. The most recent search was run on 5 February 2014. Randomised trials of the timing and volume of intravenous fluid administration in trauma patients with bleeding. Trials in which different types of intravenous fluid were compared were excluded. Two authors independently extracted data and assessed trial quality. Six trials involving a total of 2128 people were included in this review. We did not combine the results quantitatively because the interventions and patient populations were so diverse. Early versus delayed fluid administration Three trials reported mortality and two reported coagulation data.In the first trial (n = 598) the relative risk (RR) for death with early fluid administration was 1.26 (95% confidence interval (CI) 1.00 to 1.58). The weighted mean differences (WMD) for prothrombin time and partial thromboplastin time were 2.7 (95% CI 0.9 to 4.5) and 4.3 (95% CI 1.74 to 6.9) seconds, respectively.In the second trial (n = 50) the RR for death with early blood transfusion was 5.4 (95% CI 0.3 to 107.1). The WMD for partial thromboplastin time was 7.0 (95% CI 6.0 to 8.0) seconds. In the third trial (n = 1309) the RR for death with early fluid administration was 1.06 (95% CI 0.77 to 1.47). Larger versus smaller volume of fluid administration Three trials reported mortality and one reported coagulation data.In the first trial (n = 36) the RR for death with a larger volume of fluid resuscitation was 0.80 (95% CI 0.28 to 22.29). Prothrombin time and partial thromboplastin time were 14.8 and 47.3 seconds in those who received a larger volume of fluid, as compared to 13.9 and 35.1 seconds in the comparison group.In the second trial (n = 110) the RR for death with a high systolic blood pressure resuscitation target (100 mm Hg) maintained with a larger volume of fluid as compared to a low systolic blood pressure resuscitation target (70 mm Hg) maintained with a smaller volume of fluid was 1.00 (95% CI 0.26 to 3.81). In the third trial (n = 25) there were no deaths. We found no evidence from randomised controlled trials for or against early or larger volume of intravenous fluid administration in uncontrolled haemorrhage. There is continuing uncertainty about the best fluid administration strategy in bleeding trauma patients. Further randomised controlled trials are needed to establish the most effective fluid resuscitation strategy.

Emergency management of traumatic total scalp avulsion with microsurgical replantation

Total scalp avulsion is a rare but serious injury often resulting in defects of the hair-bearing skin, and it may even be life-threatening. Microsurgical hair-bearing scalp replantation is the first choice for the treatment of scalp avulsion. In this article, we describe the microsurgical replantation of two cases with total scalp avulsion. The avulsed scalp involved the hairy scalp, forehead, eyelids, ears, and part of the face. Initial management in the emergency department (ED) included correction of hemorrhagic shock with early blood transfusion, intravenous rehydration, and wound compression after rapid physical examination. A full trauma and preoperative workup prior to attempts at replantation needs to be performed to exclude any associated life-threatening injuries. Good form and function of the completely avulsed tissues and organs were achieved in both cases. Successful replantations can achieve the best esthetic and functional results when compared with other procedures. In addition to the microsurgical technique, preoperative evaluation and preparation in the ED are considered to be an important part of the successful salvage of the avulsed scalp.

Massive transfusion in multi-trauma patients

In this article, current opinions on massive transfusion will be discussed, based on three patients who received massive transfusion after major injury. Trauma is not only the leading cause of death in patients under 45 years of age, but also the most common cause for massive transfusion. Adequate recognition of the need for massive transfusion is paramount to decrease early mortality. Massive transfusion protocols have been developed to simplify and standardize transfusion administration are based on prevention of coagulopathy, acidosis and hypothermia. Transfusion not only refers to administering packed red blood cells (PRBC), but also limiting coagulopathy by means of using essential hemostatic blood products, such as fresh frozen plasma (FFP) and platelets (PLT). At our institution, a 1:1:1 ratio of PRBC:FFP:PLT is advocated, in concordance with most current literature. Massive transfusion however, can lead to complications such as transfusion induced lung injury, acute respiratory distress syndrome and multiple organ dysfunction syndrome. In this article, current literature is reviewed, and new insights regarding coagulation measurements and hemostatic products including the influence of transfusion on the immune system have been discussed. All of the three described patients in this article developed coagulopathy, acidosis and hypothermia. Their physiology was corrected by a combination of damage control surgery and early hemostatic blood transfusion. The two surviving patients did not develop any septic complications caused by massive transfusion.

Risk factors for delayed extubation in thoracic and lumbar spine surgery: a retrospective analysis of 135 patients

Extubation may be delayed after spine surgery mainly for the concerns of airway safety. Risk factors for delayed extubation in cervical spine surgery have been described to include prolonged surgery time and amount of crystalloids or blood transfused. To date, risk factors for delayed extubation in thoracic or lumbar spine surgery have not been investigated. We retrospectively reviewed 135 consecutive patients from 2006 to 2009 who underwent thoracic or lumbar spine surgery by one particular surgeon to identify risk factors for delayed extubation. Data including patient factors, surgical time, anesthetic technique, blood loss, crystalloid and colloid administration, transfusion requirements, time to transfusion, and time to extubation were collected and analyzed. Delayed extubation was defined as the patient was not extubated in the operating room at completion of the surgery. One hundred and eight patients were extubated in the OR. Delayed extubation occurred in 27 patients. Delayed extubation was significantly related to total operative time (6.6 ± 0.4 vs. 5.2 ± 0.1 h), volume of crystalloid replacement (6,018 ± 408 vs. 4,186 ± 130 cm3), volume of total colloids infused (787 ± 93 vs. 442 ± 36 cm3), intraoperative blood transfused (3.7 ± 0.5 vs. 0.7 ± 0.1 units); blood loss (2,137 ± 286 vs. 832 ± 50 cm3), and time to starting blood transfusion (106 ± 12 vs. 199 ± 9 min). Our study suggests that intraoperative factors including prolonged surgical time, significant blood loss, larger volume of crystalloid and colloid infusion, and blood transfusion may be risk factors for delayed extubation following thoracic or lumbar spine surgery. Early blood transfusion may also increase the risk of delayed extubation. Patient factors did not affect extubation time.

The Association of Early Transfusion with Acute Lung Injury in Patients with Severe Injury: Holena DN, Netzer G, Localio R. J Trauma Acute Care Surg 2012;73:825–31.

Injury from major trauma remains a significant source of morbidity and mortality worldwide. Lifesaving therapies such as early blood transfusion after traumatic injury have enabled survival or improved morbidity. As a result of the increased use of early blood transfusion after traumatic injury, the incidence of adverse effects resulting from such early transfusion has also increased, including an increase in the incidence of post-transfusion acute lung injury (ALI). Prior studies demonstrated an overall risk for development of ALI after transfusion in the first 24–48 h of hospitalization, yet did not assess if the association varied with exact time of transfusion after traumatic injury.